Summary Report for FSPSAs Ending During the Report Period Center: 57
This report shows the total number of units/fees for FSPSAs ending during the report period.
(i.e., end date of service authorization occurs during the report period). This report does not
represent all FSPSAs that overlap the report period. Note that service authorization periods may
range from 1 to 12 months and may vary in intensity from child to child.
FSPSAs ending between: 01-01-22 and 03-31-22 Date of Report: 04-16-22 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1524 FSPSA's found
Services Cpt Code Number of Number of Total Units Total Cost of Avg Fee
Children Records Authorized Auth Services Per Unit Auth
Service Coordination, Class # 01
SCONLY-SCONLY *SERVICE COORDINATION ONLY 5 5 2.088889 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 5 5 4.838889 $179.0400 $37.0000
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Subtotal (Total Children Is Unduplicated) 10 10 6.927778 $179.0400 $25.8400
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.000000 $55.7100 $55.7100
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 2 2 1.155556 $59.0200 $51.0700
AUDE -V5010 ASSESSMENT FOR HEARING AID 3 3 3.000000 $135.0000 $45.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 1 1 0.155556 $7.9400 $51.0600
OCTH -97167 OT EVAL HIGH COMPLEXITY 34 34 9.144446 $466.8300 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 3 3 0.494445 $25.2400 $51.0600
PSTH -97163 PT EVAL HIGH COMPLEXITY 9 9 2.161112 $110.3300 $51.0500
SPCH -92521 EVAL OF SPEECH FLUENCY 1 1 0.161111 $8.2200 $51.0500
SPCH -92521GT EVAL OF SPEECH FLUENCY 1 1 1.000000 $51.0500 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 28 29 21.450795 $1095.0700 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 9 9 5.574604 $248.3500 $44.5500
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Subtotal (Total Children Is Unduplicated) 52 93 45.297625 $2262.7800 $49.9500
EI Services, Class # 03
AUDE -V5160 DISPENSING FEE BINAURAL 1 2 2.000000 $460.0000 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1 2 0.877778 $43.8900 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 221 228 219.884123 $10994.2000 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.033333 $0.8300 $24.9800
CONPF -CONPF CONSULT, PT, FACE TO FACE 37 40 47.940474 $2397.0100 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 254 263 201.006348 $10050.3200 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 0.066667 $1.6700 $25.0100
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 53 53 370.571424 $9264.3000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 375 389 2608.679377 $130433.9300 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 1 1 0.714286 $35.7200 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 307 310 2054.126994 $20541.2600 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 53 53 207.428574 $14818.7100 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 2 2 11.071429 $633.2800 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 19 20 82.357146 $5883.5800 $71.4400
PHY -97110HM PT SESSION BY PT ASST 2 2 11.428572 $653.2500 $57.1600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 50 50 195.000003 $13930.8100 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 4 4 15.142858 $866.1700 $57.2000
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Subtotal (Total Children Is Unduplicated) 430 1421 6028.329386 $221008.9200 $36.6600
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Total 1524 6080.554789 $223450.7300 $36.7500
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Number of Children (Unduplicated) With at Least One Authorization 439